INCOME-OFFSET FORM
IOWA VOCATIONAL REHABILITATION SERVICES
Notice to Applicant
To:Iowa Vocational Rehabilitation Services Financial Liaison, 510 East 12th Street, Des Moines, IA 50319
Disclosure of information requested by the Iowa Vocational Rehabilitation Services (IVRS) is voluntary. However, failure to disclose certain items of information requested may result in a delay in the processing of an application for Self-Employment services, or its rejection.
Iowa Law 265-25.4.4(d) “Application procedure”
“Awards will not be made if an application has a credit history showing delinquent credit obligation including, but not limited to, unpaid income tax, delinquent child support obligation or defaulted student loans.”
The primary purpose for collecting the requested information is to assess the creditworthiness of the applicant. Efforts will be made to protect the privacy of applicants to the extent possible consistent with State law.
I hereby authorize and consent to the release of information and records bearing on my credit history; business income, all liabilities and assets including (but not limited to) child support, student loan status, tax information, etc., to representatives of Iowa Vocational Rehabilitation Services. This information will be used for the purpose of determining my eligibility for assistance within the IVRS/IDB Self-Employment program.
This authorization is valid for the length of my involvement with IVRS/IDB, not to exceed one year from the date of signing. I understand that my records are protected under the Federal Regulations governing Confidentiality and cannot be disclosed without my written consent unless otherwise provided for by the regulations. I also understand that I may revoke this consent at any time except to the extent that action has been taken on it.
My signature acknowledges that I have read the above, accept the conditions stated therein, and have received a copy of the Notice to Applicant regarding disclosure of information.
______
Client Signature Date
______
IVRS/IDB Counselor SignatureDate
ALL COUNSELORS: PLEASE READ
1. Provide signed copy to client. Retain original in VR case file.
2. IVRS Counselor Only:Forward (1) client name, (2) last four digits of Social Security number, and (3) case file number to Dawn Trenez via e- mail at: (click on address to open e-mail)
(4) In your e-mail to Dawn, cc (copy) the ISE Business Development Specialist.
4.IDB Counselor Only:(1)Include IDB client’s full Social Security Numberhere______.
(2) Print client’s name next to their signature above. (3) Send photo copy of this document to BDS.
(4) BDS will forward a paper copy on to Dawn Trenez. (Do not send full SS# via e-mail.)
Counselor will be informed by IVRS personnel either “Yes,” a client is on the Income Offset or “No,” they are not. The purpose of an Income Offset search is to determine if a client owes money to another State agency/entity. If a client is on the Income Offset, prior to proceeding further, the client must contact Administrative Services (current contact is Martha at 515.281.5202) to determine the particulars of their debt. A client must provide documentation of resolution of any State-owed debt to continue the ISE process.
R-ISE-1 (rev 12/11)